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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005678
Report Date:
10/19/2021
Date Signed:
10/19/2021 12:13:26 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
HARBOR HEIGHTS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER:
306005678
ADMINISTRATOR:
PAUL BROWN
FACILITY TYPE:
740
ADDRESS:
525 W. LA PALMA AVE
TELEPHONE:
(714) 459-3353
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
199
CENSUS:
48
DATE:
10/19/2021
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
11:29 AM
MET WITH:
Paul Brown
TIME COMPLETED:
12:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency (CCL) received a special incident report (SIR) from the facility on 10/18/2021.The date of the incident was on 10/11/2021. The SIR reported that 2 residents had an altercation. The facility staff separated the residents and checked for injuries. Staff reported that medical assistance was not required. Facility notified all the responsible parties and the primary care physicians for both residents. Responsible parties agreed that the residents should no longer be room mates and each resident was moved to a new room. Each resident now has their own room. LPA spoke with both residents. Both residents are doing well and were having lunch when the LPA visited them. LPA interviewed the Memory Care Director Rosa Avila and Facility Administrator Paul Brown. The incident was reported to the Agency (CCL) timely and the facility staff intervened and redirected both residents. The residents did not suffer any injuries. The responsible parties were notified along with the PCPs. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Administrator and a copy of the report provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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